5 Things We Shouldn’t Do

I really want you to trust your child’s doctor. I really want them to trust you, too. Partnership is key to any relationship. Recently an article was published in the Archives of Internal Medicine entitled The “Top 5” Lists in Primary Care. It sounded more like a blog post than an article. In media summaries, reporters wrote about less being more. Not surprisingly, it was right up my alley. Like I’ve said many times before, in medicine, less is often more. Partnering with your child’s doctor is essential in assuring that when nothing needs to happen, nothing does.

This list is a reminder for us all.

The group authoring the article is part of the “The Good Stewardship Working Group” and represents 22,000 physicians for the National Physicians Alliance. Their intentions: to find 5 things “not-to-do” in primary care. For pediatrics, the committee used evidence (Cochrane reviews, AAP/AAFP Guidelines, The FDA, NAEPP), experience in the office, and field testers (pediatricians) to generate a list of what to avoid/what not to do, to avoid harm. The goal is to improve health, reduce burdens both financially and physically, and ultimately to empower patients, parents, and pediatricians to avoid unnecessary testing and intervention. I’m sharing them here because good care is partnered care. Being a strong, informed parent is likely the best asset your child will ever have in a health system. Parents need to know this list. If I could tattoo it on your arm, I would. You’re the strongest and most motivated person to advocate for your child. You’re also the most likely to help avoid unnecessary and dangerous intervention alongside the doctor or nurse caring for your child. The “don’t” list according to this group:

No Antibiotics For Sore Throat Unless Child Tests Positive For Strep: Seems like a no-brainer, but it’s not. The committee asserts that most pharyngitis (throat infections) are caused by viruses, so antibiotics do no good. A “rapid strep test” is usually done in under 15 minutes in the office (the throat swab) and is over 95% correct. When it’s negative, there is no need for antibiotics. Yet research has found that patients are given antibiotics more than 1/2 the time! Without any fever, without enlarged lymph nodes, without gooey tonsils, and when a cough is present, it’s far more likely that a virus is causing the sore throat. In that case, antibiotics only cause harm like setting children up for antibiotic resistance, diarrhea, stomach upset, increased medical visits, and ultimately increased cost to all of us. Less is more. Make sure your child has the dreaded throat swab before giving them antibiotics.

No Head CT Or Diagnostic Images For Minor Head Injuries Without Loss Of Consciousness Or Other Risk Factors: Head CT after a child falls on their head is often not needed. Getting x-rays and CT scans of the head poses a risk for children, including an increased risk of cancer (the article cites as high as 1 case in every 1400 infants exposed to cranial[head] CT). Remember this blog post on the 5 things you can do to reduce radiation exposure for your child? If you child isn’t dizzy, doesn’t have external signs of injury (a huge goose egg), no changes in their nerves or neurologic function, and didn’t have a huge fall (fall from 3 ft or more, more than 5 stairs, or a bicycle-related injury, etc), or is under 2 years of age, it’s unlikely that a CT scan of their head is necessary. Getting CT scans and x-rays in low risk patients (those without above symptoms) rarely detects abnormalities that need surgery. Ensure your child needs an x-ray or CT after a fall by talking with the doctor about risks. Refer to Image Gently for more information and ways to communicate with the doctor.

Don’t Refer Patients To Specialists Early in the Course of the Problem With Ear Infections: Most cases of ear infections resolve on their own in a matter or weeks to months without any significant consequences. Early referral to a surgeon for ear tubes is likely not in your child’s best interest unless they have underlying craniofacial abnormalities, neurologic problems, significant language delay, learning problems, or structural abnormalities of the ear/ear drum. Most pediatricians I know won’t refer a healthy child with ear infections to a specialist unless they have had 6 ear infections in one season or they are unable to clear an ear infection after a number of months. Wait, watch, and support. If your worry continues, talk with the pediatrician.

Don’t Use Cough and Cold Medicines: There is little science that over-the-counter (OTC) cough and cold medication reduce cough, runny nose, or ever shorten the duration of the cold. Repeatedly research finds that the medications cause more harm than good, including consequences as terrible as death. Since OTC cough and cold medications were pulled off the market in 2007, rates of ER visits are down. This article reports that despite warnings and withdrawal from the market, over 10% of children use a cough and cold medicine every single week! Don’t do it. Less is more.

Don’t Forget To Use Inhaled Corticosteroids To Control Asthma Appropriately: This is one on the list that encourages an act of intervention to prevent long-standing complications. Research supports the use of daily inhalers with corticosteroids to help control persistent asthma symptoms in children with chronic wheezing. If your child has wheezed more than 4 times in the last 6 months or has needed oral medications (corticosteroids) for wheezing twice in a 6 month time period, your child should be on a daily inhaler to prevent asthma symptoms. Getting at-risk children on these medications will reduce ER visits, hospital admissions, and suffering. Inhaled corticosteroids are well tolerated, easy to use, low risk, and can reduce medical visits and complications. Ask your pediatrician about daily prevention if you believe your child is a persistent wheezer. We use these medications from infancy all the way through adulthood to avoid asthma attacks.

How do those sound? You headed to the tattoo parlor? Are these sensible to you? Is it hard to talk about this with your child’s doctor or nurse? Have you advocated for non-intervention before?

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10 Comments to “5 Things We Shouldn’t Do”

The timing of this couldn’t be better- my son is due for his 4 month wellness which w/ out too much detail was cancelled by our office because of non insurance coverage with his plan. As a new mom I’m trying not to be consumed w/ his immunizations being off track now from the “timeline”, but more importantly am over whelmed by having to pick a new pediatrician from a list!! Where is their a factual source for good info to me as a new mom on his overall health and the like??? The choosing of a doctor I will use my instincts and if it’s not a good fit I will move on, but can’t stress how difficult it is to filter out the nonsense from the fact when trying to get and have good information for the journey of your child’s health and well being!

That last one has been a godsend for my daughter. I worried that daily corticosteroids would stunt her growth, so I asked the pulmonologist about it. He kind of sighed (he must get that question a lot), and said that the steroids don’t stunt growth, and that kids who aren’t getting the oxygen they need aren’t growing super well either. So yay for Flovent. She’s only had one asthma episode in the last three years, and that is a near-miraculous improvement.

These do sound right on! Numbers 4 and 5 are related – I will admit to being very tempted to try cough medicines for my infant. After months of wheezing, coughing, and every cold turning into bronchiolitis, using albuterol neb treatments 5, 6 or more times a day, I was desperate to stop his coughing and wheezing. A trip to the ER during a particularly bad attack, and a second round of oral steroids led to putting him on Flovent to 2 puffs 2 times a day. It was a miraculous change. I can hardly believe he is the same baby… he hasn’t wheezed in over TWO MONTHS, and that included several colds/viral illnesses. I just wish we had gone this route sooner. He is 13 months old and has wheezed since he was 6 weeks old.

I’ve tried all sorts of coughing syrups, believe me, but none of them helps. Even though Nin Jiom Pei Pa Koa http://www.geocities.jp/ninjiom_hong_kong/index_e.htm does not eliminates the cough I like to stick to this chinese syrup I’ve been taking since I was a kid: Nin Jiom Pei Pa Koa. My grandfather is chinese, so I guess my mom got the advice from him. I was really surprised when I found that chinese market selling it here in Belgium. It does have a refreshing, soothing, sweetening effect…as long as it lasts…then back to coughing mode.

Hi Lisa. Just to clear your doubt. In TCM practice, there are two types of cough (wet & dry). This loquat syrup helps to loosen and expel phlegm effectively for “wet” cough. This syrup can be diluted with 1 part syrup, 3 part water to moisturize the throat for dry cough. But usually, I would prepare the diluted version and drink the solution at interval throughout the day, for wet or dry cough. Of course, this must be coupled by a strict diet (no fried or spicy food, no cold drinks, no chicken or oranges) for better recovery. Most of the time, my cough will go away within 3 to 4 days. Hope this helps.

I have a question regarding seeing specialists. I may have broken that rule. My four year old daughter has repeated ear infections. Often her eardrum ruptures. I understand that all this does is alleviate the pressure on her membrane but fear that with repeated ruptures there could be some scarring and loss of hearing. In December of 2010 we went to the Children’s ENT. They recommended that we take out her tonsils and adenoids (which were VERY large and they thought that removing them might help reduce the infections/allergies/etc.) and that they would decide on ear tubes in surgery. Ear tubes were indeed put in (there was still a lot of very old goop in there- Dr. Oh had a term for the elastic like mucous but I don’t remember it). However, since the surgery we have continued to have ear infections and now they’re starting to have an odor. At her four year appointment we finished off the required vaccinations and about 2-3 weeks later we were back in the office for antibiotics. They cultured her ear and one of the things we vaccinated against (is it NVST?) was found in the culture. Her pediatrician said we’d continue with the ear drop antibiotics (which did seem to clear it up) but now less than 2 months later we’ve got another infection. Is this normal?? Could it be that there’s some sort of super bug in there that we’re not killing? Is this wait-and-see approach, as opposed to an offensive approach the best route? I tried calling to see if you were taking new patients, sadly you’re not but any recommendations on course of treatment (I do have another ENT appointment at Children’s but not until August) and pediatrician recommendations is much appreciated. We are in Seattle.

Oh Liz, you ask many good questions. First of all, breaking the above rule has sense when your child isn’t improving, has complications or predispositions to infections, or is not responding to treatment and has ongoing drainage suggesting an infection. Wait and see often works but chronic ear infections may demand variant options. I’ll leave it up to both your ENT and your peds to help advise you. Why don’t you follow up with Dr Ou’s office and ask to speak to him about this?
I’m so sorry my practice is closed!! It’s frustrating to me, too. Regarding finding a pediatrician, I recommend you ask your friends and get feedback. Those that you trust can give you great information and feedback about the pediatrician they see but also how the office runs/etc. Our sons’ pediatrician is at VM Sandpoint clinic and I think they are a fantastic group! https://www.virginiamason.org/body.cfm?id=342&action=detail&ref=35

I totally agree with these. But I have a huuuuge pet peeve related to #1. I have a degree in microbiology and my thesis was related to drug-resistance (MDRTB but same applies to others). It boggles my mind the number of times we have been OFFERED antibiotics by doctors (even my pediatrician who I trust, love, adore, and have never had to question on ANYTHING else!) when they were not necessary. I’ve always said “would it be reasonable just to wait and see if this clears up?” (ear infections, upper respiratory infections, sore throats, etc.) and the answer has been YES all but one time. Then WHY are you even suggesting these drugs?? I understand that parents often WANT antibiotics for small infections, but to me that culture will not change unless physicians educate people about the use of antibiotics. In fact, I would go so far as to say that is it completely their responsibility to prescribe them only when absolutely indicated, regardless of what the parents/patients want – even if it upsets the patients and makes them leave. Doctors are perfectly willing to see that they are responsible for ensuring that controlled substances are prescribed only when needed, and are willing to tell patients “no” and risk losing those patients when they are seeking narcotics. Why are antibiotics any different? Because they are not as dangerous? I disagree – drug resistance is hugely scary. To me narcotic drug-seeking patients are no different than uneducated patients who think antibiotics are some great cure-all and want them when they are not indicated. Doctors have the knowledge to make the right treatment decisions, and they have the responsibility that comes with that prescription pad.

Hi Vera
I am a GP and emergency doctor and I agree very much to the fact that we prescribe too much antibiotics. But the problem is very simple: When you prescribe it all patients will be happy because the symptoms will get better for sure. If you don’t and you should have (which happens all the time when you have a probabilistic approach) or there is an bacterial superinfection you seem to be a bad doctor because you should have known.
And yes you can get tired of fighting with patients and parents. Especially when your colleagues don’t.
Just last week I got yelled on and insulted by a mother who wanted antibiotics “as usual” for a viral fever of her 3 year old boy.
So sometimes when I am at the end of a 24h shift I let go and do not argue anymore….sorry

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